Sedation and Analgesia in Paediatric Intensive Care Units

Abstract

The indications for sedation in the paediatric intensive care unit (PICU) patient are varied ranging from short term use for various procedures to prolonged administration to provide comfort during mechanical ventilation. When faced with the decision to institute sedation, the healthcare provider must make three decisions: the agent to be used, the route of delivery, and the mode of administration (intermittent versus continuous). There are several agents that have been used to provide sedation in the PICU patient including the inhalational anaesthetic agents, benzodiazepines, opioids, ketamine, propofol, chloral hydrate, phenothiazines, and the barbiturates. This review describes the various agents for sedation and discusses their advantages and disadvantages as they pertain to the PICU. Consequences of and treatment strategies for long term problems with prolonged sedation including tolerance, physical dependency, and withdrawal are reviewed.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. “Assessment remains troublesome”

“…Symptoms of opioid withdrawal in newborns of drugaddicted mothers are generally divided into three main groups: overstimulation of the central nervous system (CNS), gastrointestinal dysfunction, and autonomic dysregulation or sympathetic hyperactivity [4,15,38]. Table 2 lists the described signs and symptoms of withdrawal in children relating to either opioids or benzodiazepines, or combined use, broken down for these three groups.…”

“…This illustrates the practical limitation for describing specific benzodiazepine-related withdrawal symptoms in the PICU. From clinical experience we know that benzodiazepines and opioids are usually administered in combination for sedation and analgesia, from several days to weeks as reflected in the literature [1,38]. Given the overlap in symptoms, it is hard to ascribe withdrawal symptoms to either opioids or benzodiazepines [21,29,32].…”

“…Evaluation of the various studies reveals that children in a PICU receiving benzodiazepines and/or opioids for 5 days or longer are at risk for developing withdrawal symptoms [17,[23][24][25][27][28][29][30][31]. Benzodiazepine and/or opioid withdrawal symptoms may occur if these medications are abruptly stopped or tapered off too rapidly in children showing physical dependence [38]. Manifestations typically occur 8-48 h after discontinuation.…”

“…However, in the absence of a validated and reliable instrument for children, several authors have opted for the NAS [24,25,27,30]. Other authors designed observation checklists themselves, including 5-13 symptoms [25,38,31]. These observation checklists have not been properly validated for use in children [25,31].…”

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement

“…Separation from family and home; the fear of machines and procedures; disruption of sleep, alarms, and noises are common reasons for anxiety in children requiring sedation (1). The cause of pain can be surgical or can result from diagnostic and therapeutic procedures such as suctioning, position changes, and peripheral IV placement (2).…”